Malaria in pregnancy remains a major public health problem, especially in sub-Saharan Africa. Pregnant women are more susceptible to malaria because of changes in immunity and because the parasite can accumulate in the placenta. Consequences include maternal anaemia, severe malaria, miscarriage, stillbirth, preterm birth and low birth weight, which increases the risk of newborn death. Midwives and nurses in antenatal clinics are the frontline of prevention.
In high-transmission areas, women with some immunity may carry parasites in the placenta without symptoms, yet still develop anaemia and have low-birth-weight babies. That’s why prevention is recommended for all pregnant women in these areas, not just those who feel unwell.
Prevention package
1. Intermittent preventive treatment (IPTp-SP)
- In areas of moderate to high malaria transmission in Africa, WHO recommends sulfadoxine-pyrimethamine (SP) for all pregnant women, starting as early as possible in the second trimester (not before 13 weeks).
- Doses are given at each scheduled antenatal contact, at least one month apart, with the goal of at least three doses during pregnancy.
- Ideally given as directly observed therapy in the clinic.
- SP can be taken with or without food.
- Do not give SP to women taking co-trimoxazole prophylaxis (for example, many women living with HIV), because of the risk of adverse reactions.
- Folic acid: high-dose folic acid (5 mg or more) can reduce the effectiveness of SP; the standard antenatal dose (0.4 mg) can be given safely alongside it.
2. Insecticide-treated nets (ITNs)
- Give or ensure access to a long-lasting insecticidal net early in pregnancy.
- Teach correct use: sleep under it every night, tuck it in, repair holes.
- Encourage nets for young children too.
3. Early antenatal care
WHO recommends at least eight antenatal contacts. Early booking makes it possible to give IPTp on time and screen for anaemia.
Recognising malaria in pregnancy
- Fever, chills, headache, body aches, vomiting.
- Any pregnant woman with fever in an endemic area should be tested with a rapid diagnostic test (RDT) or microscopy.
- Check haemoglobin for anaemia.
Treatment of uncomplicated malaria
- WHO updated its guidance so that artemether-lumefantrine is now recommended to treat uncomplicated falciparum malaria in the first trimester, as well as other artemisinin-based combination therapies (ACTs) in the second and third trimesters, following evidence on safety.
- Follow your national malaria treatment guidelines, which set the specific medicines and doses.
- Ensure the full course is completed.
Severe malaria in pregnancy: an emergency
Pregnant women are at higher risk of severe malaria, including cerebral malaria, severe anaemia, hypoglycaemia and pulmonary oedema. Signs include confusion, convulsions, inability to sit or stand, repeated vomiting, breathing difficulty, jaundice, dark urine or very low urine output.
- IV or IM artesunate is the treatment of choice in all trimesters.
- Check blood glucose frequently: both malaria and quinine (if used) cause hypoglycaemia.
- Monitor fluids carefully: pregnant women with severe malaria are at risk of pulmonary oedema.
- Monitor the fetus; involve obstetric teams.
- See our severe malaria guide.
Women living with HIV
HIV increases the risk and severity of malaria in pregnancy. Women on co-trimoxazole prophylaxis should not receive SP; co-trimoxazole itself provides some protection. Bed nets are especially important.
Counselling points
- Explain why SP is given even when she feels well.
- Address myths (for example, that malaria medicines cause miscarriage).
- Encourage her to come quickly if she develops fever.
- Encourage partner involvement: nets for the whole family.
Related: Anaemia in pregnancy · Preterm labour
Based on WHO Guidelines for malaria (latest update) and WHO antenatal care recommendations. Educational content: follow national malaria guidelines.